Defining the need for blood and blood products transfusion following suicide bombing attacks on a civilian population: a level I single-centre experience.

INTRODUCTION: Knowledge of patterns of blood use in the care of mass casualty settings is important for preparedness of medical centre resources and for maximising survival when blood supplies are limited. Our objectives were to review of our experience with the use of blood products and define the utilisation of blood transfusion following suicide bombing attacks. PATIENTS AND METHODS: We conducted a retrospective analysis of blood and blood product transfusion following civilian bombing attacks at a level I trauma centre in Jerusalem, Israel from 2000 to 2005. The study group consisted of 137 patients who were admitted following 17 suicide bombing attacks which were carried out in Jerusalem during the 5-year period. Demographic data, number of units of blood and blood products transfused and the need for massive transfusions were recorded and analyzed. RESULTS: Fifty-three patients received blood transfusions (38.7%). There were 33 males (62.2%) with a median ISS of 13 (range 4-25). These 53 patients received 524 PRBC, 42 WB, and 449 FFP. The mean number of PRBC transfused/admitted patient was 3.82 units (range 0-59). Thirty patients (21.9%) received 236 PRBC (45% of total PRBC) at the first 2h. The ratio of ordered to transfused blood was 946:524. The FFP:PRBC ratio for all transfused patients was 1:1.17. The number of PRBC transfused per attack correlated with the number of patients admitted per attack. The most commonly transfused blood type was A (52.3%). Only 18 units of uncrossed-matched blood were transfused (3.3% of total). 14 patients (10.2%) received massive transfusions. These patients received 399 PRBC (76.1% of total units transfused) and the average number of PRBC transfused was 28.5/patient (10-59). CONCLUSIONS: More than 1/3 of casualties admitted following civilian bombing attacks received transfusions, most in the first 2h. Large-scale attacks will require more blood and blood products than small-scale attacks. Twice the number of PRBC ordered than transfused reflects a known trend for over-triage during the initial assessment following bombing attacks. One tenth of patients received massive transfusion.

Indicators of the need for ICU admission following suicide bombing attacks.

INTRODUCTION: Critical hospital resources, especially the demand for ICU beds, are usually limited following mass casualty incidents such as suicide bombing attacks (SBA). Our primary objective was to identify easily diagnosed external signs of injury that will serve as indicators of the need for ICU admission. Our secondary objective was to analyze under- and over-triage following suicidal bombing attacks. METHODS: A database was collected prospectively from patients who were admitted to Hadassah University Hospital Level I Trauma Centre, Jerusalem, Israel from August 2001-August 2005 following a SBA. One hundred and sixty four victims of 17 suicide bombing attacks were divided into two groups according to ICU and non-ICU admission. RESULTS: There were 86 patients in the ICU group (52.4%) and 78 patients in the non-ICU group (47.6%). Patients in the ICU group required significantly more operating room time compared with patients in the non-ICU group (59.3% vs. 25.6%, respectively, p=0.0003). For the ICU group, median ICU stay was 4 days (IQR 2 to 8.25 days). On multivariable analysis only the presence of facial fractures (p=0.014), peripheral vascular injury (p=0.015), injury≥4 body areas (p=0.002) and skull fractures (p=0.017) were found to be independent predictors of the need for ICU admission. Sixteen survivors (19.5%) in the ICU group were admitted to the ICU for one day only (ICU-LOS=1) and were defined as over-triaged. Median ISS for this group was significantly lower compared with patients who were admitted to the ICU for >1 day (ICU-LOS>1). This group of over-triaged patients could not be distinguished from the other ICU patients based on external signs of trauma. None of the patients in the non-ICU group were subsequently transferred to the ICU. CONCLUSIONS: Our results show that following SBA, injury to ≥4 areas, and certain types of injuries such as facial and skull fractures, and peripheral vascular injury, can serve as surrogates of severe trauma and the need for ICU admission. Over-triage rates following SBA can be limited by a concerted, focused plan implemented by dedicated personnel and by the liberal utilization of imaging studies.